Casa Bonita Convalescent Hospital
535 E Bonita Ave., San Dimas, CA 91773
Citation Number: 950005435
Citation Date: 12/19/2008
Violation Date: 10/27/2007
Class: AA
Penalty: $ 100,000

On 10/27/07, a 90 year old resident of Casa Bonita's sub-acute unit died because it did not have a system in place to prevent her tracheostomy tube from disconnecting from a ventilator. It also failed to monitor its alarm system that was supposed to alert its staff to such emergencies. Upon arriving at the facility, the resident's daughter discovered her mother disconnected from the ventilator and unresponsive, but the staff had not detected or responded to the life threatening emergency. After the daughter alerted the staff, she reported they "were running around like they did not know what to do." The resident died within 30 minutes of being discovered by her daughter. The remote alarm outside the resident's door had not sounded when she became disconnected from the ventilator. The investigation found that the alarm had been silenced less than an hour before the resident's death. The daughter reported she had complained to staff that she frequently discovered the alarm turned off. The facility did not establish a policy for checking the alarms until after the resident's death. The respiratory therapist caring for the resident at the time of her death reported he was unaware of her careplan, which stated she was at risk for becoming disconnected from the ventilator due to coughing related to congestion. The facility did not provide a device to prevent the tube from disconnecting. The neglect caused the resident's death.